The nurse is caring for a 12-year-old patient who complains of ear pain to the right ear for four days. Pain rated 7/10 on the numerical scale. Temperature is 99.9°F (37.7°C), pulse is 87, blood pressure is 115/64, oxygen saturation is 100 percent on room air.
Scenario update: The external auditory canal is clear and not reddened. The tympanic membrane is bulging and red. The patient reports having had reoccurring ear infections since childhood.
1.
Which symptoms are concerning (identifying cues)?
2.
What additional information is needed (analyzing cues)?
3.
What do you think is going on with the patient (prioritizing hypothesis)?
A patient presents to the doctor complaining of a sore throat for the past three days. Upon physical assessment, the nurse notes the patient’s throat is red, tonsils measure grade 3+, and voice is hoarse. Pertinent past medical history includes strep throat, tonsillectomy, and seasonal allergies.
4.
What assessment data provide conflicting information?
5.
What should the nurse do prior to documenting the findings?
6.
What additional assessment data are needed?
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